N.J. Admin. Code § 11:4-42.8

Current through Register Vol. 56, No. 24, December 18, 2024

Section 11:4-42.8 - Provisions setting forth pre-authorization requirements

(a) Group policies and certificates providing health insurance in which some portion of the benefits are subject to pre-authorization provisions shall comply with the following:

1. There shall be a caption for the pre-authorization provision in both the policies and certificates that shall clearly state in prominent boldface type that benefits will be reduced for noncompliance with the requirements of the pre-authorization provision.

2. The pre-authorization provision shall include a process by which a covered person shall be able to appeal benefit denials (including, but not limited to, hospitalization admission denials, a reduction of benefits payable, rejected admissions and non-reviewed admissions), which process shall be described in detail and shall state a reasonable time period within which the covered person may expect the insurer (or any entity with which the insurer has contracted to perform such reviews on its behalf) to respond.

3. The penalty for noncompliance shall not exceed 50 percent of the charges which would otherwise be covered under the contract, policy or certificate. Schedules of penalties to be offered to policyholders (outlining the range of penalties for non-compliance with the pre-authorization provision) shall be submitted to the Department with the policy form filing.

4. If the pre-authorization provision incorporates an emergency treatment post-notification requirement with a notice deadline and penalty, the provision shall include a statement that post-deadline notice shall be accepted and the penalty waived if the covered person provides notification as soon as reasonably possible.

5. Inpatient and/or outpatient treatment for alcoholism as described at N.J.S.A. 17B:27-46.1 shall only be subject to pre-authorization provisions if all inpatient and/or outpatient treatments for other injuries and illnesses are subject to the same review.

(b) Incorporation of the required pre-authorization warning text in a certificate booklet, through certificate riders and/or insert pages shall not be acceptable.

(c) If an identification card is used for benefit certification purposes, a pre-authorization requirement warning similar to that contained in the policy and certificate shall be displayed on the identification card, along with a telephone number by which to contact the insurer regarding the pre-authorization provision.

1. A sample of the identification card along with a copy of any promotional and/or informational material which describes the preauthorization requirement shall be included with the initial form submission made to the Department.

N.J. Admin. Code § 11:4-42.8

Amended by 51 N.J.R. 618(a), effective 5/6/2019